Triage complications resulting from COVID-19

April 10, 2020

Individual physicians should not be determining critical care and ventilator use.

One of the main differences between providing care in ordinary times and during a pandemic, such as the world is experiencing with the novel coronavirus, is the need to depart from what’s done in the best interests of the individual patient when there are limited resources, says Carl Coleman, JD, professor at Seton Hall University School of Law in Newark, N.J. He specializes in the legal, ethical, and public policy implications of medical treatment, research, and public health.

“When there are limited resources, it’s not possible to give everything to patients that might benefit them. Thinking about it from that perspective, it’s about what’s best for the community. That’s the shift-to a thoughtful use of limited resources to achieve the best outcome for the population as a whole,” says Coleman, acknowledging that this requires a mental shift in perspective.

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Efforts to increase access to resources

Heroic efforts are underway in New York CityBoston, and other parts of the country to increase resource capacity. Of primary concern are access to doctors and nurses to treat patients with Covid-19, and the availability of ventilators and hospital beds.

According to the Society of Critical Care Medicine, there may be more than 200,000 ventilators in the United States, but shortages are expected. In response, U.S. automakers Ford and General Motors are partnering with ventilator manufacturers to ramp up production, but the Washington Post reported that these efforts will likely deliver ventilators after the peak of Covid-19 cases projected to occur in mid-April.

Kathy Butler, JD, a St. Louis-based attorney at Greensfelder, Hemker, and Gale law firm, says that her healthcare clients are looking at ways to stretch their resources by looking at alternative treatment sites and considering the need to double up patients on ventilators. 

 

Institutional guidelines

The Hastings Center, a bioethics research institute and think tank based in Garrison, N.Y. recommends that healthcare organization’s institutional ethics services conduct focused preparation for the “[t]he foreseeable uncertainty and distress that clinicians and teams will face under contingency or crisis conditions call for focused preparation.”

“The real crisis is going to be in the hospital setting,” says Coleman. “The thing that people are most worried about is that there aren’t enough ventilators, or there soon will not be enough in some places. So, decisions will have to be made about who should get priority for a ventilator and potentially taking people off ventilators who aren’t responding in order to give them to those with [a] better prognosis.”

He stresses that access to critical care or a ventilator aren’t decisions that should be made by individual physicians. Key aspects of guidance should include the following:

  • A transparent process for applying the guidelines

  • A process for reviewing decisions

  • A required separation between the person who decides about access to resources and the physician caring for the patient.

The people participating in developing this guidance for healthcare organizations should include medical ethicists, doctors, nurses, administrators, lawyers, and social workers, advises Coleman.

In addition to paying attention to their healthcare organization’s protocols, Kathryn Zeiler, JD, law professor at Boston University, advises physicians to look for guidance from their state’s department of public health, as well as the American Medical Association and their state’s medical association. These guidelines, especially about triage, should be short and very clear, she adds.

 

AMA’s guidance on triage decisions during pandemics 

According to the American Medical Association’s (AMA) guidance on public health emergencies, such as pandemics, the “commitment of fidelity to the individual patient is counterbalanced by the need to protect the welfare of a population of patients... and to be prudent stewards of limited societal resources entrusted to them.”

She explains that the guidelines tell doctors what to take into account and what not to take into account regarding triage.

Here are two circumstances doctors should take into account:

  • The allocation of any scarce resource, including their time, based on the urgency of the patient's need as the doctor assesses it. 

  • The likelihood and anticipated duration of the benefit of the doctor’s intervention and the change in the patient’s quality of life. 

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Zeiler also gives two examples of characteristics a doctor can’t take into account:

  • Social worth. These considerations come into play when a doctor is presented with, for example, a patient who’s a scientist developing a cure for Covid-19 and the person who picks up the trash. The doctor shouldn’t take into account a person's employment, she explains.

  • The person’s contribution to the illness. For example, if the patient says they haven’t practiced social distancing, a doctor can’t take that into account in determining triage. 

 

Document decision-making

Kay Van Wey, JD, a Dallas-based personal-injury attorney and patient safety advocate, points out that practices will also need to keep in mind access to care for patients who are managing chronic or other non-Covid-19-related conditions. Covid-19 testing will strain resources at lab testing facilities, in particular. 

Her advice to clinicians is to document their decision-making. For example, if a patient needs a STAT lab test but the lab is closed, the clinician can recommend that the patient order an at-home test online, and that should be documented. In addition, the clinician can advise the patient to go to the emergency room if their symptoms get worse and have a nurse call the patient the next day to check in. 

Patients with symptoms of Covid-19 will also be calling physician practices. Butler advises physicians to triage these patients based on their symptoms and related comorbidities and direct them to the appropriate level of care, per the Centers for Disease Control and Prevention’s guidelines. For example, an otherwise healthy patient in her thirties will likely be told to manage the condition at home and, hopefully, survive. She contrasts that with a patient with a heart condition or diabetes who’s having trouble breathing; that patient needs to go to the emergency room because they may crash and need someone to help them.